To enable integration between the care management team and the safety-net primary care system, ADS sub-contracts with four large safety-net primary care clinic systems within King County, including Harborview Medical Center (the sole public hospital serving King County); Neighborcare Community Health Centers; Healthpoint Community Health Centers; and Sea Mar Community Health Centers. Each of the contracted clinic systems has between four and six primary care clinics, the latter three systems are Federally Qualified Health Centers (FQHC). The contracted clinic systems care for large numbers of patients who have complex psychosocial needs (such as joblessness, homelessness, food insufficiency, low health literacy, and limited English proficiency), and co-occurring medical, mental health and substance abuse disorders. The extraordinary medical and psychosocial burden of these patients is reflected in aggregate results from assessments done on an initial group of program enrollees (See Table 19.1).

Table 19.1 Demographic and Clinical Characteristics of KCCP’s initial enrollees (N = 256)

KCCP also provides a limited amount of financial support for each of the partnering clinic systems to hire one clinical care coordinator (CCC). The CCCs provide a link between the community-based ADS clinical team and the primary care medical homes within each of the partnering clinic systems. The CCCs assist with outreach to difficult-to-contact clients; assist the KCCP clinical team in communicating with primary care providers; assure that clinic-based services are coordinated and do not overlap with the services provided by the KCCP clinical team; champion the KCCP clinical team and program within their clinic systems; and assist in assuring a smooth hand-off back into the full care of the primary care medical home when clients transition from intensive care management.

In addition to the CCCs described above, there are three other key elements to KCCP systems integration: (1) information technology, (2) motivational interviewing (MI), and (3) participation in community forums. Each of these will be described below.

Information technology

KCCP has built a HIPAA-compliant, web-based clinical information system that enables sharing of patient-specific clinical information across the partnering organizations. This system allows documentation and tracking of client contacts, as well as reporting capability with respect to initial assessments and outcomes using validated clinical instruments (for example, PHQ-9). The KCCP clinical team has direct access to the Electronic Health Record (EHR) of one of the larger partnering organizations as well. The possibility of providing such EHR access across all partners is under active discussion.

Motivational Interviewing (MI)

KCCP’s shared patient-centered approach to client interaction and care management is grounded in the spirit and method of MI (Rollnick et al. 2008). Individuals from all of the partnering systems have jointly participated in extensive MI training – an activity designed to promote a consistent, client-centered experiences across clinical systems.

Participation in community forums

Members of the KCCP core clinical team participate in monthly meetings of community-based organizations whose services overlap with or may involve KCCP clients. These include the King County Healthcare for the Homeless program and Harborview Medical Center’s High Utilizers Work Group.

The KCCP clinical team

The KCCP intensive care management clinical team is composed of three full-time RNs, two social workers (MSWs) with chemical dependency training, and a bachelor’s level individual trained and experienced in chemical dependency counseling who serves as the “engagement specialist.” These individuals have each received one year of intensive training and coaching in MI (See Table 19.2).

Table 19.2 Motivational Interviewing Training Components

In addition, the clinical team participates in regular trainings that focus on behaviorally-oriented strategies for managing affective disorders commonly encountered in the chronically ill Medicaid population, such as depression and anxiety. The latter trainings are sponsored by a local, non-profit health plan as part of a state and locally-funded effort to improve access to mental health care for the poor and vulnerable populations seen in safety-net clinics. Thus, comprehensive ongoing training on relevant clinical skills, day-to-day clinical supervision by a nurse supervisor experienced in oversight of community-based clinical programs, and weekly case-conferences with the KCCP Medical Director, are essential underpinnings of KCCP’s care management intervention.

Selection, engagement, and assessment of clients

High-risk patients eligible for intensive care management are drawn from a larger, target population of SSI-eligible Medicaid clients who reside within King County and have received care from one of the participating clinic systems within the prior 12 months. A predictive modeling computer program developed by DSHS is used to identify those clients within the target population who are at particularly high risk of future health care utilization. There are approximately 8,000 clients in the target population, of whom about 1,500 have been designated as high-risk based on predictive modeling. Because KCCP is being evaluated using a randomized controlled trial (RCT) methodology that has not yet been completed, eligible clients are randomized either to receive the KCCP care management intervention, or to an abeyance group that will become eligible for the intervention after the RCT is completed.

A list of high-risk patients randomized to the intervention is provided to the ADS clinical team. A dedicated member of the clinical team (the engagement specialist) contacts those clients eligible for the intervention using a purposeful, informed approach that has yielded a greater than 50% engagement rate (defined as referred clients having completed an in-person comprehensive RN assessment; see West et al., 2010). Key elements of the engagement approach include: (1) checking with the partnering clinic where the patient appears to be established for primary care to cross-reference and assure the most updated contact information;(2) scheduling work so that outbound calls can be made at different times of day including evenings and weekends; (3) utilizing the spirit and method of MI in interacting with patients; and (4) asking an individual from the clinic to contact the patient and encourage participation in KCCP if the patient is reluctant to speak with the engagement specialist.

After clients have agreed to enroll in KCCP care management, they are referred to an RN member of the clinical team who arranges for an initial in-person meeting and comprehensive assessment. Typically, this meeting occurs at the home of the client; when this is not possible, arrangements are made to meet the client at an alternative site (such as the physician’s office). The initial assessment takes approximately 60 to 90 minutes, and includes administration of validated instruments to screen for common mental illness, substance abuse issues, and health literacy; assessment of chronic medical conditions, chronic pain, and functional status; review of medications; identification of psychosocial issues that may impact abilities to access care or follow through on care plans; and collaborative goal-setting that focuses on and takes account of the client’s expressed needs, both medical and psychosocial.

Subsequent to the initial assessment, the RN arranges to join the client at one or more physician appointments, one of which must be with the client’s primary care provider. Prior to the appointment, the RN coaches the patient regarding strategies that can improve the quality of communication between the client and the client’s physician. Within the confines of the exam room, the RN may, with permission of the client, communicate important information that has been ascertained during the initial assessment and may be relevant to the patient’s ongoing care. At this time, the goals established by the client with the help of the RN may be shared with the treating physician. The RN may also assist in assuring that clinical information is shared across providers (primary care, medical/surgical specialists, and mental health specialists) who are involved in the client’s care.

Managing clients

Once clients are enrolled, assessed, and have had at least one joint appointment with their RN care manager and primary care physician, the RN may choose to engage one of the MSW team members in helping to connect the client to needed community resources, or provide assistance with the management of chemical dependency issues.

Clients are provided with contact information (phone numbers) for their care management team (RN and/or MSW). The frequency of contact is at the discretion of the clinical care team and client. In general, more unstable or severely chronically ill patients receive more frequent contact, which may occur via phone or in-person. In-person contacts are typically arranged to coincide with physician visits. Physicians caring for patients enrolled in KCCP are also provided the care manager’s contact information and encouraged to contact the care manager for assistance in caring for or concerns about the patient. Key elements of the KCCP care model are summarized in Table 19.3.

Table 19.3 Key Elements of the KCCP Care Model

KCCP clinical staff has embraced the spirit and method of MI in their face-to-face interactions with clients. In case conferences with the KCCP Medical Director, the RNs and social workers have described in their own words the nature of these interactions. For example, one RN, in describing an interaction with a client, stated, “Affirm the client’s perceptions and feelings, and suspicion melts away.” This same RN indicated that she tells clients, “I’m not here to change you, or make you do anything you don’t want to do” (Lessler 2010).

Collaboratively establishing client-centered goals is a priority for the care managers. The manner in which care managers approach goal setting – and, in particular, the content of their interactions with clients around a goal – is well captured in a key informant interview conducted as part of a qualitative analysis of the KCCP care management intervention. In the words of a member of the KCCP clinical team, “It helps us to know what their [the client’s] agenda is. Our agenda might not be their agenda, and so when you’re using MI and you’re actively listening, a lot of times, without even talking, you can find out what’s important to them, and so through that, I’m able to know where to go with them. I’m not going to spin my wheels working with them here because it’s not important to them. They just said X, Y, and Z are important to them, so instead I’ll put my energy there” (Cristofalo et al. 2010).

The application of MI principles and methods by the KCCP clinical team in their interactions with clients is well captured in the following vignette.

A.G. is a 38-year-old Native American man with generalized anxiety disorder and alcohol dependence, as well as several chronic medical conditions. At his initial meeting with the KCCP RN care manager, A.G. stated, “People have told me what to do; I don’t want you telling me what to do.” The RN responded to A.G., “I’m not going to tell you what to do; I’m going to walk beside you regardless of the path you take.” At the third encounter between A.G. and the nurse, which happened to be in-person, A.G. stated, “I’m thinking about making a change, but I’m not ready today, and I’m not sure I will be ready in two days or two weeks.” In subsequent meetings, both in-person and over the phone, the nurse describes reflections on the patient’s ambivalence, affirmations for his thinking about change, and finally, more detailed problem-solving conversations. Ultimately, after six months in care management, A.G. enrolled in a 30-day inpatient chemical dependency treatment program (Lessler 2010).

Layered on top of the individual, patient-centered interactions that KCCP care managers have with clients, is a complex web of care coordination that includes advocacy and connection to community-based resources. The richness of this layer of care management is captured in the following summary of three months of care management provided by an RN care manager to her client:

“Client one has significant cognitive deficits and substance abuse dependencies (narcotics and alcohol). Because of his cognitive deficits the client needed a tremendous amount of feedback and reminders regarding his goals, care, and appointments. He calls his RN care manager almost every day at times asking for reassurance and confirmation of appointments. On enrollment in KCCP, he did not have a primary care provider. Between March and mid-May 2009, the KCCP team helped the client establish primary care. During this time the RN care manager also attended a mental health appointment with the client and began the process of aiding the client in going to inpatient chemical dependency treatment by obtaining a letter of clearance for him. The RN care manager also got the client established with neurology rehabilitation specialty care, accompanying him to his first appointment, and coordinated care with a specialty clinic after the patient presented at an emergency room with an acute hand injury” (Krupski et al. 2009).

Evidence of program success

The overall success of the patient-centered model employed by KCCP is reflected in a recent phone survey of patients who were program participants (Krupski et al. 2010):

• 98% said they had a good, trusting relationship with their nurse or social worker.
  
• 92% said the health care goals they developed with their nurse included their most important health care needs.
  
• 91% said the program helped them feel they could take charge of their health.
  
• 90% were able to reach at least one of the health care goals they developed with their nurse.
  
• 82% said the program helped them get health care needs met that they could not have met on their own.

Likewise, in key informant interviews, physicians with enrolled patients indicated that the program was helpful to them in providing better care for their patients. For example, interviewed physicians perceived that the program increased the likelihood that patients would keep appointments with them; they commented that when nurses attended clinic appointments with patients they felt more informed about care that was being provided by other physicians involved in the patient’s care (Cristofalo et al. 2010).

Overall, key elements of the success that KCCP has enjoyed to-date relate importantly to the program’s core clinical team, and the clinic-based care coordinators having successfully embraced the spirit – non-judgmental, encouraging of client self-worth and following client authority – and methods of MI (Linden et al. 2010). Achieving this level of commitment to and demonstrated skill in using MI has required extensive training and ongoing support for developing and refining MI skills. Other factors that have contributed to KCCP’s success include the face-to-face interaction of care managers with clients; the participation of care managers in physician visits; the monitoring and availability of care managers to clients (both in person and via telephone); and the ability of care managers to work with clients over a twelve-month time period, with more time allowed if needed.

Program challenges

The KCCP clinical team has also faced challenges. The clinical and psychosocial needs of clients in care management are often profound, and can be overwhelming for those involved in their care. Even with extensive training and institutional support, burn-out of care management team members is a considerable risk. KCCP has experienced RN turnover since its inception that has, at times, created program instability. In response to concerns about workload, KCCP has adjusted RN caseloads downward from approximately 100 clients per RN to 67 to 70 clients per RN/team.

KCCP has also been impacted by the challenges faced by its safety-net clinic partners. For example, the KCCP care management team has noted that primary care provider attrition within these clinics has sometimes interrupted continuity of care, making it difficult for patients to understand and follow through on care plans. More generally, the shortage of primary care providers has sometimes led to problems with timely access to care.

From a systems perspective, KCCP has attempted to knit together a community-based RN-led, multidisciplinary care management model with the safety-net clinics that provide medical homes for the vast majority of enrolled clients. Creating this system has been enabled by the fact that participating organizations share a mission of caring for underserved and vulnerable populations. In addition, the development of explicit contractual obligations, and the provision of financial resources to participating clinic systems has led to both commitment and accountability on the part of all partners.

Early in the development of KCCP, it became clear that, given the resources available, no one clinic system could adequately support an intensive care management model for its most severely medically and mentally ill, as well as socially and economically disadvantaged patients. KCCP centralizes intensive care management services for such clients within a single community-based agency (ADS) that is experienced in providing community-based care. This resource has now been leveraged across safety-net clinic systems in a manner that provides tight linkages between the clinic systems and the core service provider. It is especially important to note that ADS is not confined by the walls of a clinic; it is able to put a clinical team “on the ground” because it has a history of working with disabled and chronically ill clients who are homebound. Thus, it has at its disposal important infrastructure (for example, a motor pool for use by KCCP team members), knowledge, and experience that support putting a clinical team out in the community; clinic systems typically do not have this unusual blend of resources. In this way, KCCP has been able to provide intensive care management services that optimally leverage community resources, which are also integrally linked to the primary care medical homes of clients.

While celebrating a modicum of success, KCCP also faces considerable challenges. Previous research indicates that a key element of successful care management programs is the involvement and buy-in of treating physicians (Berenson & Howell 2009; Bodenheimer & Berry-Millett 2009). In this regard, a recent formative evaluation indicated that KCCP’s ties to the physicians who worked within partnering clinics were not as strong as they could or should be. This evaluation also indicated that some of the physicians in clinic systems served by KCCP may not share KCCP’s commitment to MI’s approach for eliciting and strengthening motivation to change. Assuring more broad-based physician familiarity with and trust in KCCP’s intensive care management program will require enhanced educational efforts by KCCP to clinic systems and physicians (Cristofalo et al. 2010).

Conclusions

Research indicates that successful care management programs include the following attributes: (1) patient selection, (2) in-person encounters including home visits, (3) specially trained care managers with low case loads, (4) multidisciplinary teams including physicians, (5) informal caregivers and family assisting the patient, and (6) use of coaching (Berenson & Howell 2009; Bodenheimer & Berry-Millett 2009). KCCP possesses, in varying degrees, the key attributes of a successful care management program for patients with complex health needs. It has the added strength of providing care management through a central, community-based organization that leverages an expensive and scarce resource across multiple safety-net clinic systems; it links care managers with the primary care medical homes and physicians of clients; and it connects clients and their families to community resources. Preliminary outcomes based on a formative evaluation of KCCP are encouraging; the extent to which KCCP is successful in affecting more definitive clinical (for example, mortality) and utilization (that is, costs) outcomes will be better understood when data from the ongoing RCT evaluating KCCP become available.

References

Berenson, R. & Howell, J. (2009) Structuring, Financing and Paying for Effective Care Coordination. The National Coalition of Care Coordination (N3C), Washington, DC.

Bodenheimer, T. & Berry-Millett, R. (2009) Care Management of Patients with Complex Health Care Needs. Research Synthesis Report Number 19. The Robert Wood Johnson Foundation, Princeton, NJ.

Ciechanowski, P., Wagner, E., Schmaling, K., et al. (2004) Community-integrated home-based depression treatment in older adults: a randomized controlled trial. The Journal of the American Medical Association, 291, 1569–1577.

Cristofalo, M., Krupski, T., Jenkins, L., et al. (2010) Chronic Care Management Intervention: A Qualitative Analysis of Key Informant Account. Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations, Seattle, WA.

Krupski, T., Cristofalo, M., Atkins, D., et al. (2009) Qualitative Analyses of Client Contacts that Occurred During the First Three Months of the Rethinking Care Project. Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations, Seattle, WA.

Krupski, T., Cristofalo, M., Jenkins, L., et al. (2010) Client Perspectives on the Rethinking Care Program: Report of a Telephone Survey. Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations, Seattle, WA.

Lessler, D. (2010) Meeting notes for KCCP Care Management Team Meeting (Personal communication, September 10, 2010).

Linden, A., Butterworth, S.W., Prochaska, J. (2010) Motivational interviewing-based health coaching as a chronic intervention. Journal of Evaluation in Clinical Practice, 16, 166–174.

Rollnick, S., Miller, W.R., & Butler, C.C. (2008) Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press, New York, NY.

West, I.I., Joesch, J.M., Atkins, D., et al. (2010). Clients Assigned to the Rethinking Care Program Intervention: How Do Clients Who Started an Assessment Differ From Those Who Did Not? Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations, Seattle, WA.

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